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Vascular access for hemodialysis( AVF )

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Vascular Access for hemodialysis

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Vascular access for hemodialysis( AVF )

  1. 1. 1
  2. 2. VASCULAR ACCESS IN HEMODIALYSIS Dr. IRFAN ELAHI Consultant Nephrologist Mayo Hospital Lahore BY
  3. 3. 3 Native Arteriovenous fistula (AVF) Prosthetic arterio-venous graft (AVG) Cathater Temporary double lumen cathater Permanent Cathater THERE ARE 3 TYPES OF VASCULAR ACCESS
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  7. 7. A V GRAFTS 7
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  10. 10. 10 Benefits of Arteriovenous Fistula (AVF) Lowest rate of failures and complications Longevity Lowest costs BENEFITS OF ARTERIOVENOUS FISTULA (AVF)
  11. 11. 11 Definition Process by which a fistula becomes suitable for cannulation (ie, develops adequate flow, wall thickness, and diameter). FISTULA MATURATION
  12. 12. Rule of 6’s In general, a mature fistula should: Be a minimum of 6 mm in diameter with discernible margins when a tourniquet is in place Be less than 6 mm deep Have a blood flow greater than 600 mL/min Be evaluated for non maturation 4–6 weeks after surgical creation FISTULA MATURATION 12
  13. 13. 13 The fistula should be examined regularly following surgery. At 4 weeks post surgery, the fistula should be evaluated specifically for non maturation. CLINICAL CLARIFICATION
  14. 14. 14 Look, listen, and feel the new AVF at every dialysis treatment After the scar heals, begin assessing AVF using a “gentle” tourniquet placed high in the axilla area Instruct patient to start access exercises after healing Document patient education as well as condition and maturation of the AVF DURING AVF MATURATION PROCESS
  15. 15. 15 Vessel diameter must be 4–6 mm Vessel walls should toughen and be firm to the touch There should be no prominent collateral veins MATURING FISTULA
  16. 16. 16 TOURNIQUET
  17. 17. 17 IS NEW AVF MATURE AND READY FOR CANNULATION? AVF
  18. 18. 18 Vein looks large enough Vein feels prominent and straight Vein has a strong thrill and good bruit IS AVF MATURE AND READY FOR INITIAL CANNULATION?
  19. 19. 19 What diagnostic tools or techniques can be used to determine if an AVF is ready for cannulation? Can the same tools or techniques be used to select the cannulation sites? FISTULA MATURATION
  20. 20. 20 Duplex Doppler study Physical exam by the: Nephrologist Nephrology nurse Surgeon Angiogram (fistulogram) DIAGNOSTIC TOOLS/TECHNIQUES TO DETERMINE IF AN AVF IS READY
  21. 21. 21 Physical Exam Look, Listen, and Feel Using; Eyes Ears Fingertips BEST TOOL/TECHNIQUE?
  22. 22. 22 Physical Exam Firm, no longer mushy Vessel wall thickening Vessel diameter enlargement (to 4–6 mm) Absence of prominent collateral vein If in doubt, “Just Say No” MATURING FISTULA
  23. 23. 23 Look for Changes compared to opposite extremity Skin color/circulation Skin integrity Edema Drainage Vessel size/cannulation areas Aneurysm Hematoma Bruising INSPECTION
  24. 24. 24 Temperature Change Warmth = possible infection Cold = decreased blood supply PALPATION
  25. 25. Thrill PALPATION 25 Palpation can be started at the anastomosis Thrill diminishes evenly along access length Change can be felt at the site of a stenosis; becomes “pulse-like” at the site of a stenosis Stenosis may also be identified as a narrowed area
  26. 26. 26 Feel for Size, Depth, Diameter, and Straightness of AVF Feel the entire AVF from arterial anastomosis all the way up the vein Evaluate for possible cannulation sites = superficial, straight vein section with adequate and consistent vein diameter PALPATION
  27. 27. 27 Listen for Bruit Listen to entire access every treatment Note changes in sound characteristics (bruit): A well-functioning fistula should have a continuous, machinery-like bruit on auscultation An obstructed (stenotic) fistula may have a discontinuous and pulse-like bruit rather than a continuous one—and also may be louder and high- pitched or “whistling” Louder at stenosis than at anastomosis AUSCULTATION
  28. 28. 28 Communicate assessment findings with access team, including surgeon Check maturity progress every session Assure evaluation by surgeon 4 weeks post-op Intervene if there is no progress at 4 weeks or AVF is not mature and ready for cannulation at 6–8 weeks POST-OP FOLLOW-UP
  29. 29. 29 Must have: Physician’s order to cannulate Experienced, qualified staff person who is successful with new fistula cannulations Use of a tourniquet or some form of vessel-engorgement technique (e.g, staff or patient compressing the vein) BASIC REQUIREMENTS FOR CANNULATION
  30. 30. 30 17-gauge needle is strongly recommended for initial cannulation A fistula may appear and feel ready to cannulate, but the vessel wall may still be fragile and unable to tolerate the needle puncture The smaller needle gauge helps to decrease injury to the vessel and prevents a large infiltration, hematoma, compression of the vessel, and possible clotting of the AVF should any cannulation complication occur (ie, infiltration) NEEDLE GAUGE
  31. 31. 31 MATCH NEEDLE GAUGE TO BLOOD FLOW RATE (BFR) Needle Gauge Maximum BFR 17-gauge < 300 mL/min 16-gauge 300-350 mL/min 15-gauge 350–450 mL/min 14-gauge > 450 mL/min
  32. 32. 32 USE BACK-EYE NEEDLES Back-eye opening allows blood intake from both sides of the needle; can be used as arterial or venous needle Non–back-eye needle—for venous use only Arterial needle Venous needle
  33. 33. 33 BACK-EYE NEEDLE FLOW Allows blood to enter or exit from both the bevel and back-eye
  34. 34. 34 Always cannulate the venous needle with the direction of the blood flow Always cannulate the arterial needle cannulation toward the blood inflow or with the blood outflow NEEDLE DIRECTION
  35. 35. 35 Venous needle directed back toward the heart Arterial needle directed toward the arterial anastomosi s (retrograde) Needle Direction
  36. 36. 36 Venous needle directed back toward the heart Arterial needle also directed back toward the heart (antegrade) Needle Direction
  37. 37. 37 Always use a tourniquet, regardless of the size or appearance of vessel Use of the tourniquet helps to engorge, visualize, palpate, and stabilize the AVF Use 20–35° angle for needle insertion for an AVF NEW AVF CANNULATION PROTOCOL
  38. 38. 38 “WET” NEEDLE
  39. 39. 39 On removal of needles, for hemostasis: Use 2-finger compression Never use clamps Hold sites for 10 minutes—no peeking NEW AVF CANNULATION: ADDITIONAL POINTS
  40. 40. 40 Check fistula daily for a thrill and bruit Check for signs and symptoms of infection or other complications Write instructions for fistula care EDUCATION FOR PATIENTS
  41. 41. 41 Thrill is undetectable Patient becomes feverish, dehydrated, or experiences low blood pressure CALL THE NEPHROLOGIST/PHYSICIAN
  42. 42. CANNULATION SITE SELECTION AND PREPARATION 42
  43. 43. 43 Assess AVF before every cannulation Compare arms for changes in skin color, circulation, integrity Inspect Access extremity for central or outflow vein stenosis Distal areas of extremity for steal syndrome Access for vessel size, cannulation areas, infection, aneurysms PHYSICAL ASSESSMENT
  44. 44. PHYSICAL ASSESSMENT 44 Palpate Temperature change may mean infection or stenosis Change in thrill may mean stenosis Auscultate Listen to entire access for changes in bruit that indicate stenosis
  45. 45. 45 Look and feel for a straight segment of AVF Segment must be as long as the needle length (ie, 1″ minimum) Stay at least 1.5 from the AVF anastomosis″ The arterial and venous needles need to be 1 to 1.5″ ″ apart Avoid curves, flat spots, and aneurysms to prevent complications IDENTIFY IDEAL SEGMENT OF AVF
  46. 46. 46 Dialysis patients have more Staphylococcus spp (SA and MRSA) on their skin and in their nares (nose) than the general population Dialysis staff can also have a higher rate of staph carriage Common route of transmission of staph is from the nose to the skin to the vascular access = infection SITE PREPARATION
  47. 47. If possible, patient should wash the access with antibacterial soap before coming to the chair Staph is the leading cause of infection in dialysis patients SKIN PREPARATION 47
  48. 48. 48 Proper needle-site preparation by both the patient and staff reduces infection rates Once the skin site is properly cleansed, the skin should not be touched with bare hands or gloved hands If touched, re-prep the skin All site selection should be done prior to the final skin preparation SKIN PREPARATION
  49. 49. 49 Wet insertion site for 30 sec Allow to air-dry for ≈30 sec Do not blot or wipe APPLYING CHLORHEXIDINE GLUCONATE
  50. 50. 50 Saturate sterile gauze pad Clean sites with circular motion Wait 2 minutes before proceeding APPLYING SODIUM HYPOCHLORITE
  51. 51. 51 Proper needle-site preparation reduces infection rates Start where you are going to place the needle (the black dot) and cleanse in a circular, outward motion Do not touch skin after cleansing area PROPER CLEANSING TECHNIQUE
  52. 52. 52 KDOQI Says For all vascular accesses,aseptic technique should be used for all cannulation and catheter incertion procedures (evidence) SAYS WHO? 1. Locate, inspect and palpate the needle cannulation sites prior to skin preparation. Repeat prep if the skin is touched by the patient or staff once the prep has been applied, but the cannulation not completed. 2. Wash access site using an antibacterial soap or scrub and water. 3. Cleanse the skin by applying 2% chlorhexidine gluconate/70% isopropyl alcohol and/or 10% povidone iodine as per manufacturer’s instructions for use. Notes:  2% chlorhexidine gluconate/70% isopropyl alcohol antiseptic has a rapid (30 s) and persistent (up to 48 hr) antimicrobial activity on the skin. Apply solution using back and forth friction scrub for 30 seconds. Allow area to dry. Do not blot the solution.
  53. 53. 53 Needle fear and pain with needle insertion are very real issues for many hemodialysis patients Various pain-control options can be utilized to make the cannulation procedure less stressful for patients ANESTHETIC OPTIONS FOR PAIN CONTROL
  54. 54. 54 Lidocaine injected under the skin and above the vessel Advantage: Numbs the area prior to the cannulation procedure Disadvantages: Can cause scarring, vasoconstriction, keloid formation,burning with injection, and poses a needle-stick risk INTRADERMAL ANESTHETICS
  55. 55. 55 Topical sprays (ethyl chloride) can be used to numb the skin sites Advantage: Noninvasive method of numbing the skin Disadvantages: Nonsterile, requires patient-specific bottle to prevent cross-contamination, may discolor or damage skin with long-term use, flammable contents in bottle Method: Spray arterial site, prep skin, then insert needle immediately; repeat for venous site TOPICAL SPRAYS
  56. 56. 56 Wash skin first Apply 1 hour before dialysis Cover with plastic wrap Prior to cannulation, remove cream, wash/prep skin USING TOPICAL CREAMS
  57. 57. 57 Tourniquet required for all cannulations Apply tightly enough to engorge vessel TOURNIQUET USE
  58. 58. CANNULATION TECHNIQUES 55
  59. 59. 59 Site-Rotation Also known as: Rope ladder Rotating sites CANNULATION TECHNIQUES Buttonhole Also known as: Constant-site Same-site
  60. 60. 60 Take your time Cannulation is achieved in a gentle manner Determine the depth of the access during your assessment—this will determine the angle of entry into the fistula IMPORTANT TIPS
  61. 61. 61 Cannulation sites are rotated up and down the AVF to use its entire length Classic technique used in most dialysis centers SITE-ROTATION TECHNIQUE
  62. 62. 62 Look for straight areas of at least 1 for each cannulation″ site If you try to “straighten out” by pulling on the vessel to cannulate, the vessel will retract into its original position when released and lead to an infiltration Avoid aneurysms and flat or thinned-out areas Stay 1.5 away from the anastomosis″ Keep the needles at least 1.5 apart″ Each treatment requires 2 new sites LOCATING THE CANNULATION SITE
  63. 63. 63 Proper site-rotation cannulation technique with rotation of both venous and arterial needle sites Venous site-rotation cannulation sites Arterial site-rotation cannulation sites
  64. 64. 64 Improper site-rotation cannulation technique with rotation of both venous and arterial needle sites Poor venous site rotation Poor arterial site rotation
  65. 65. 65 “One-site–itis” occurs when you stick the needle in the same general area, session after session Causes aneurysm and stenosis formation “ONE-SITE–ITIS” Practice of repeatedly puncturing same area, AKA “one-site–itis”
  66. 66. 66 Caused by sticking needles in the same general area Aneurysm can also result from stenosis beyond the aneurysm, causing elevated back pressure AVF ANEURYSM
  67. 67. 67 Watch the orientation of the needle bevel, and avoid turning your wrist If the bevel enters sideways, this can cause cutting of the vessel and/or a sidewall infiltration Use only a back-eye needle for the arterial needle The venous needle can be back-eye or non–back-eye NEEDLE INSERTION
  68. 68. 68 Use of tourniquet should be mandatory Stabilize vessel Pull skin taut toward the cannulator to allow easier needle insertion (compresses nerve endings, blocking pain sensation to the brain for about 20 seconds) THREE-POINT TECHNIQUE
  69. 69. 69 “L” TECHNIQUE Hold thumb and index finger as an “L” Thumb holds skin taut over fistula Index finger stabilizes and engorges
  70. 70. 70 Rule of Thumb 20–35° angles for fistulae 45° for grafts ANGLES OF ENTRY Reality Not every access fits the rule of thumb; some AV fistulae are very shallow and a lesser angle can be used You will need to carefully assess the depth of the access and adjust the angle of cannulation accordingly
  71. 71. 71 Secure wings Sterile gauze or adhesive bandage over insertion site Chevron to prevent dislodging Additional tape as needed
  72. 72. 72 Prep skin prior to cannulation Stabilize the skin and the AVF PREPARING FOR CANNULATION
  73. 73. 73 Use an approximately 20–35° angle of insertion depending on the depth of the access The angle is from the skin to the needle hub First, enter the skin and tissue above the AVF vessel, then the vessel INSERTION OF NEEDLE
  74. 74. 74 Once the AVF vessel is entered, the blood flashback is visible in the needle tubing Level out and advance the needle with very minimal pressure ADVANCING THE NEEDLE
  75. 75. 75 Do not “flip” or rotate the bevel of the needle 180° Flipping can lead to stretching of the needle-insertion site and cause oozing during the dialysis treatment PLACEMENT IS CRUCIAL
  76. 76. 76 Apply gauze dressing without pressure Remove needle at insertion angle Apply pressure with 2 fingers Do not use excessive pressure Hold for 10–12 minutes, no peeking Use stethoscope to check for bruit after applying dressing to stick site NEEDLE REMOVAL
  77. 77. 77 USE A STETHOSCOPE TO CHECK FOR BRUIT
  78. 78. 78 Apply adhesive bandages Dispose of needles in biohazard sharps container per guidelines specified in the Occupational Safety and Health Act (OSHA) NEEDLE REMOVAL
  79. 79. 79 Pull needle completely from the vein before pushing down on the needle site Hold direct pressure for 10 minutes without “peeking”—no exceptions Do not use clamps unless absolutely necessary! POST-TREATMENT HEMOSTASIS
  80. 80. 80 Method in which an individual cannulates the AV fistula in the exact same spot, at the same angle and depth of penetration every time A scar tissue tunnel track develops, allowing for the use of a buttonhole (blunt) fistula needle BUTTONHOLE TECHNIQUE Procedure
  81. 81. 81 May prolong AVF lifespan Reduces pain, bleeding, infiltration, infection Virtually eliminates missed cannulations Promotes self-care and self-dialysis Use blunt needles, which require no safety device ADVANTAGES
  82. 82. 82 Requires same cannulator, same angle, same location Concerns of “one-site−itis” Difficult with fistula covered by: Heavily scarred skin Large amount of subcutaneous tissue DISADVANTAGES
  83. 83. 83 AVF BUTTONHOLE TECHNIQUE Buttonhole sites
  84. 84. 84 TWO BUTTONHOLE SITES Buttonhole sites
  85. 85. 85 Change blunt needles once the track is formed Blunt needles prevent continued cutting of the buttonhole track and new entry site of the AVF vessel Blunt needles prevent infiltrations, bleeding from around the needle sites, and resistance to the needle insertion into the track and vessel CHANGING TO BLUNT NEEDLES
  86. 86. 86 NEEDLES—SHARP AND BLUNT
  87. 87. 87 A ridge is starting to develop A hole is starting to develop This site is not yet ready for a blunt needle A DEVELOPING BUTTONHOLE
  88. 88. 88 Needle inserted into the buttonhole tunnel track, but the angle is not aligned with the vessel flap The needle can bounce on the vein and not displace the vessel flap BUTTONHOLE: WRONG ANGLE OF INSERTION
  89. 89. 89 Adjust angle to find the flap Lift up and down on the needle to readjust the angle until the needle drops into the vessel flap BUTTONHOLE: ADJUSTED ANGLE OF INSERTION
  90. 90. Causes BUTTONHOLE: ADJUSTED ANGLE OF INSERTION 90 Moving needle from angle used to enter the skin, arm positioning not in routine place, or patient weight gain or loss
  91. 91. 91 It may be possible to speed the development of buttonhole sites by cannulating the sites every day It is helpful to switch over to blunt needles as soon as possible Long-term use of sharp needles will cut adjacent tissues, enlarge the hole, and cause bleeding along the needle path HELPFUL HINTS…
  92. 92. 92 If it is impossible to have only 1 cannulator, additional buttonhole sites can be developed at the same time using a second cannulator If your patient is hospitalized and the acute hospital renal team does not know how to access a buttonhole, they can: Rotate sites using standard sharp needles as long as they stay ¾ away from the buttonhole tracks″ OR Have the patient self-cannulate (if the patient has been trained) MORE HELPFUL HINTS…
  93. 93. 93 Plan outreach to the acute team and educate regarding buttonhole technique Continue access monitoring and surveillance, even if patient is dialyzing at home Inform patients that laminated procedure cards and videos are available STILL MORE HELPFUL HINTS…
  94. 94. 94 Bleeding can occur around the needles during dialysis if: You are using sharp needles and have cut the track The track has stretched because of trying to direct the needle instead of following the track You have made a new track and torn tissue TROUBLESHOOTING THE BUTTONHOLE
  95. 95. 95 If, after the weekend, you have trouble with blunt needles, switch to sharp needles for that day, being careful not to cut the track If a site is not progressing, it is acceptable to abandon that site and find another site TROUBLESHOOTING THE BUTTONHOLE
  96. 96. 96 Difficulty re-entering the fistula vein Can occur when transitioning from sharp to blunt needles The blunt needle “bounces” on the vessel and will not enter the vessel Corrective action: Change the needle angle slightly until the vessel flap is located and needle drops into the vessel If it persists, return to sharp needle for a few sessions and then try blunt needle again TROUBLESHOOTING THE BUTTONHOLE
  97. 97. COMPLICATIONS 95
  98. 98. 98 Bleeding during treatment (oozing around needle or infiltration) = fragile vessel wall or back wall penetration; don’t flip the needles Bleeding post–needle removal = fragile vessel wall or needle trauma or inadequate pressure at puncture sites Review needle-removal technique. Improper pressure with needle withdrawal = vessel damage BLEEDING
  99. 99. BLEEDING 99 A pattern of prolonged bleeding post–needle removal may indicate stenosis or clotting disorder. Evaluate bleeding after 20 minutes Educate patients about post-treatment hemostasis and what to do at home should the needle site re-bleed
  100. 100. 100 INFILTRATION = HEMATOMA
  101. 101. 101 Don’t flip needle Don’t lift needle in vein Flush with NSS PREVENT CANNULATION INFILTRATIONS
  102. 102. 102 Apply gauze without pressure Remove needle at insertion angle Apply pressure with 2 fingers Hold pressure 10–12 minutes PREVENT POSTDIALYSIS INFILTRATIONS
  103. 103. 103 Elevate arm above heart Ice 20 minutes on/20 minutes off for 24 hours Warm compresses after 24 hours Let fistula rest Second infiltration: Notify vascular access team Don’t use AVF until directed TREATING INFILTRATIONS
  104. 104. 104 If the fistula infiltrates, let it “rest” until the swelling is resolved ( KDOQI Guidelines) If the fistula infiltrates a second time, the RN should notify the vascular access team, including the surgeon, as soon as possible for intervention Don’t use that AVF until further directed INFILTRATIONS IN NEW AVF
  105. 105. 102 Check for flashback and aspirate Flush with NSS to ensure the needle flushes with ease and there are no signs or symptoms of infiltration Saline causes much less damage and discomfort than blood if an infiltration occurs HOW TO PREVENT INFILTRATIONS
  106. 106. 106 If bruising or hematoma occurs after dialysis, the surface skin site has sealed but the needle hole in the vessel wall has not Use 2 fingers per site for hemostasis It is crucial to apply pressure to both the skin and access wall POST-CANNULATION BRUISING AND HEMATOMA
  107. 107. 107 May be due to location or position of needle(s) May need to change direction of arterial needle If poor flow persists after next session despite changing needle locations, refer to surgeon for evaluation and possible treatment options Use tourniquet for cannulation only! Do not leave in place for entire treatment!!! POOR FLOW
  108. 108. 108 Caused by stenosis as vessel narrowing increases “back pressure,” causing vessel distension and weakening of vessel wall May also be causedor aggravated by frequent cannulations in the same area ANEURYSM
  109. 109. 109 Most common complication Causes: IV, CVC, lines Surgery to create AVF Aneurysms May be caused by the back pressure associated with stenosis Needle-stick injury STENOSIS
  110. 110. 110 Frequent cause of early fistula failure Juxta-anastomotic stenosis most common STENOSIS Stenosis
  111. 111. 111 Juxta-anastomotic (most common stenosis in AVF) Mid-access Outflow Central vessel TYPES OF STENOSES Outflow Central-vein Mid-access InflowForearm AVF
  112. 112. 112 CENTRAL-VEIN STENOSIS
  113. 113. 113 DISTENDED, OBSTRUCTED LEFT SHOULDER VEINS INDICATIVE OF CENTRAL-VEIN STENOSIS
  114. 114. 114 Clotting of the extracorporeal circuit 2 or more times/month Persistently swollen access extremity Changes in bruit or thrill (ie, becomes pulse-like) Difficult needle placement Blood squirts out during cannulation Elevated venous pressures CLUES TO STENOSIS
  115. 115. 115 Excessively negative pre-pump AP Decreased blood pump speeds Inability to achieve BFR Changes in Kt/V and URR Recirculation Prolonged postdialysis bleeding Frequent episodes of access thrombosis CLUES TO STENOSIS
  116. 116. 116 Surgical/technical problems Preexisting anatomic lesions (eg, old IV injury) Premature use Poor blood flow Hypotension Hypercoagulation Fistula compression THROMBOSIS
  117. 117. 117 AV fistulas have lowest risk of infection of any vascular access type. However… Each pre- and post-treatment exam should include: Checking for signs/symptoms of infection, including: Changes of skin over access area Redness Increase in temperature Swelling, hardness Drainage from incision, needle sites Tenderness or pain INFECTION
  118. 118. INFECTION 118 Patient complaints without other indications of Malaise Fever
  119. 119. 119 Prevention General hygiene Pretreatment washing of access extremity Hand washing, before and after cannulation No scratching, irritation of skin of access extremity Precannulation Appropriate skin antisepsis Sufficient antiseptic-skin contact time Cannulate while antiseptic is wet or dry, as directed Cannulation Maintain needle sterility Do not cannulate through scabs or abraded areas PREVENTION OF INFECTION
  120. 120. 120 Steal syndrome is a constellation of symptoms related to ischemia (inadequate blood supply to the hand) caused by the AVF “stealing” blood away from the extremity Steal causes hypoxia (lack of oxygen) to the tissues of the hand, resulting in severe pain and identified by nail bed discoloration, a cool hand, and a weak or absent pulse STEAL SYNDROME/ISCHEMIA
  121. 121. STEAL SYNDROME/ISCHEMIA 121 Neurological and soft tissue damage to the hand can occur, resulting in mobility limitations (eg, grip strength, dexterity), loss of function, ulcerations, necrosis Steal syndrome/ischemia is estimated to occur in approximately 5% of vascular access patients, mostly those with diabetes and peripheral vascular disease (PVD)
  122. 122. 122 “CLAW HAND” CONTRACTURE FROM STEAL SYNDROME
  123. 123. 123 Steal symptoms may improve due to the development of collateral circulation Procedures, such as the DRIL (distal revascularization-interval ligation), can successfully treat steal and ischemia Individuals who are at high risk for developing acute steal are: Patients with diabetic neuropathy Patients with PVD STEAL SYNDROME/ISCHEMIA
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